A Formula for disaster

by Ellen Sokol

PENANG, MALAYSIA - In 1984, when Nestle signed an agreement pledging to abide by the World Health Organization (WHO)/UNICEF International Code of Marketing Breast-milk Substitutes, consumer leaders agreed to suspend the 7-year boycott against the Swiss food giant. The boycott leaders felt a genuine sense of accomplishment following an almost decade-long fight. Unfortunately, the battle over infant formula promotion continues today, nearly eight years later.

The importance of a healthy decision

 The stakes in the ongoing battle are high, because infant formula companies' marketing efforts strongly influence women's decision to breastfeed newborns or to use breastmilk substitutes, and that decision has tremendously important implications for the health of infants.

 There is nothing that equals breastfeeding in providing proper nourishment for infants. Breastmilk has the advantage of containing antibodies that help protect the baby against many common childhood illnesses. It is sterile, always at the right temperature, inexpensive and nearly every mother has more than enough for her baby. There is also an important relationship between breastfeeding and child spacing.

 Babies who are not breastfed are fed with some type of substitute, usually by bottle. For bottle feeding to be safe, there must be clean water, fuel and facilities to boil the water and sterilize the equipment, adequate income to be able to afford the milk powder and a level of literacy that allows for the mixing and sterilizing instructions to be carefully followed.

In the developing world, the risk of death for infants who do not breastfeed is 10 to 15 times greater in the first 3 to 4 months of life than for babies who are fed only breastmilk. Despite the important role that breastfeeding plays in preventing malnutrition and infection in infants and young children, the prevalence and duration of breastfeeding have declined in many parts of the world.

 As far back as 1974, public interest groups advocating for better infant health and the World Health Assembly, the official governing body of WHO, identified aggressive and often inappropriate marketing of breastmilk substitutes as a significant factor contributing to the alarming decline in breastfeeding rates and an associated increase in young infants' morbidity rates worldwide.

 In October 1979, UNICEF and WHO organized a Meeting on Infant and Young Child Feeding that was attended by 150 representatives of governments, public-interest organizations, the infant food industry and experts in related disciplines. The main outcome of this meeting was the recommendation that "there should be an international code of marketing of infant formula and other related products used as breast-milk substitutes." Two years later, the World Health Assembly approved the final version of the International Code.

Marketing malnutrition

 Industry claims notwithstanding, manufacturers and marketers of infant formula, foods and feeding bottles routinely break the International Code. "Breaking the Rules 1991," a report issued by the International Baby Food Action Network (IBFAN) in October 1991, describes in detail hundreds of violations by more than 80 companies. Dr. Idrian Resnick, executive director of IBFAN's U.S.-based group, says the "formula companies' claim that they comply with the Code is proved false by this report. The formula industry, led by Nestle and American Home Products, must make fundamental changes in its marketing schemes to be in genuine compliance with the Code." According to an IBFAN survey, the worst offenders are: Nestle; Wyeth, a subsidiary of American Home Products (AHP); two German companies, Milupa and Hipp and Meiji, a Japanese corporation.

 Not all of the news is bad. "Breaking the Rules 1991" also indicates that WHO and UNICEF's adoption of the International Code and the boycott of Nestle has led to the decline of some unethical marketing practices. At least in developing countries, it is rare to find baby pictures or inadequate instructions and warnings on infant formula labels. And advertisements rarely reach the general public.

Yet some of the Japanese companies refuse to follow the pack even on these basics. In Karachi, Pakistan, giant billboards loom over streets and television stations broadcast advertisements beckoning consumers to buy Meiji's infant formulas. Maternity wards all over Asia are decorated with posters of beautiful "Snow Brand" babies.

 And many of the positive policy changes health activists have wrung from the baby food companies are offset by the industry's marketing and promotion of new infant food products. Almost every infant formula company now markets a product generically referred to as "follow-up" formula. Depending on the brand, follow-up formulas are aimed at babies from the ages of anywhere between three months and three years. The companies apparently hope to escape the prohibitions of the International Code by calling the product something other than infant formula and marketing it for slightly older babies.

 Health advocates have criticized follow-up formulas, with the World Health Assembly declaring in 1986 that "the practice being introduced in some countries of providing infants with specially formulated milks (so-called æfollow-up' milks) is not necessary." Yet in North America and Europe, Nestle and its subsidiary Carnation advertise follow-up milks in parenting magazines. Most of the infant formula companies advertise them heavily in professional journals all over the world.

As pernicious as corporate attempts to skirt the International Code with follow-up formulas are advertising campaigns for follow-up formula which indirectly - but undeniably - promote infant formula. Nestle, for example, markets infant formula under various brand names such as Nan-1 and Lactogen-1. It markets a corresponding follow-up formula, such as Nan-2 and Lactogen-2, for each infant formula. Since Nan-1 and Nan-2 have the same label design in slightly different shades of blue, any promotion of Nan-2 serves to promote Nan-1 as well. In one private hospital in Northeast Thailand, piles of leaflets advertising three different brands of Nestle infant and follow-up formulas are available for the taking. And in Abidjan, Ivory Coast, several hospitals display wall posters advertising Wyeth's "SMA 2eme age" (a follow-up milk recommended for babies from the fifth month) which picture a logo that matches the logo on SMA infant formula.

 A similar problem has cropped up in the marketing of formulas for special needs. The companies have developed a myriad of new products such as formulas for low-birth- weight infants, those they claim are hypoallergenic and those for babies with lactose intolerance. These products, like the follow-up formulas, are often no more than sales boosters for infant formula.

 This was never better demonstrated than in the Philippines, which enacted legislation to control the marketing of certain infant food products in 1986. Soon after the Philippine law was implemented, Nestle and Wyeth-Suaco, the Philippine subsidiary of AHP's Wyeth, approached members of the Philippine government with a request to exempt their low- birth-weight formulas from the provisions of the law. This product would not be commercially available, but would be donated for those babies who often could not thrive on breastmilk alone, the companies asserted. They brought neonatologists along with them to back up the scientific basis of their request.

Shortly thereafter, the real reason for the companies' intense lobbying was discovered. Wyeth-Suaco's marketing director had sent letters to all retailers of Wyeth products announcing the availability of a new special low-birth-weight formula. The letter explained to retailers that the new formula would only be available as a free service to hospital nurseries and that it would boost their sales of standard infant formula because "mothers will surely buy S-26 Standard right after a short stay on LBW, hence, more S-26 sales!"

The price of free formula

 Probably the most recurrent violation of the International Code is the industry practice of donating carton upon carton of infant formula to hospitals.

Hospitals receiving free supplies start babies on formula - at no cost to the hospital or to the mother - but when the mother leaves the hospital, she must buy the expensive formula. According to economist Richard Jolly of UNICEF, many "hospitals think, at least for the first day or so, ælet's give the mother a rest and have a bottle or two bottles before moving to breastfeeding.' There's lots of evidence to show that even a bottle or two in those first days reduces the likelihood of a mother breastfeeding for a sufficient period by as much as one-third."

 Through its survey, IBFAN discovered that although the practice was condemned by the World Health Assembly in 1986, companies still donate enough formula to many hospitals to enable nearly every baby to be bottle-fed. Health activists resumed the Nestle boycott because of the corporation's refusal to stop donating formula, and American Home Products' donations have sparked a new boycott of that company in certain countries.

By Nestle's own estimates, it gives free supplies of formula to hospitals in 45 developing countries. Wyeth admits to donations of formula in 25 nations. The extent of the donations is illustrated by IBFAN activists' discovery, during a January 1991 visit to a Panama City hospital, that Nestle had recently donated 600 cans of Carnation Goodstart while the U.S. company Mead-Johnson had been donating 260 cans of Enfalac each month. (One can is enough to feed a newborn for a full week.) Only 200 babies are born at the hospital each month.

 Until very recently, Nestle defended its policy of donating free supplies to hospitals, even intimating that it would be unethical for the company to discontinue the practice. Francois Perroud, Nestle vice president for press relations, told the BBC in 1988 that "infant formula in developing countries is now less than 1 percent of our consolidated sales. It would be very easy simply to drop this matter, be rid of the controversy. Why don't we do it? Because we believe we fulfill a need."

 But the evidence indicates that companies do not make these donations for charitable reasons. Not one company donates supplies in Bangladesh or Burkina Faso, two of the poorest countries in the world. In contrast, in Canada, the biggest U.S. manufacturers bid up to C$500,000 for the "privilege" of supplying Canada's largest maternity hospital with free formula. At Sumpaprasit hospital in Thailand, one nurse stated recently that "there are now eight different companies that ask to donate formula to our hospital. We had to set up a policy of monthly rotations because we do not want to favor any particular company." Such eagerness strongly suggests that companies give away formula because it is a successful marketing technique.

The companies even donate formula to hospitals in countries that prohibit the practice. In Malaysia, where government hospitals are not permitted to accept free supplies, one health worker reports that a number of companies, Nestle and Wyeth in particular, make use of a tender system which enables them to sell formula to hospitals at prices as ridiculously low as US$.04 per kilo. In the Philippines, where national legislation specifically prohibits donations of infant formula supplies, the companies conveniently neglect to collect payment on invoices for delivered quantities of infant formula.

 Nestle still stalling

 Nestle's approach to free supplies has frustrated the groups advocating an end to the practice. As part of the agreement ending the first Nestle boycott in 1984, Nestle promised to abide by the final verdicts of UNICEF and WHO on the matter. In 1986, the World Health Assembly finally acted by resolving that maternity wards and hospitals should obtain small amounts of required infant formula "though normal procurement channels and not through free or subsidized supplies."

 Instead of fulfilling its commitment and changing its policies to abide by the WHA resolution, Nestle employed its lawyers to find ways to circumvent it. When health activists applied additional pressure, Nestle announced that it was studying the problem in a few selected countries to determine the effect of ending free supplies. But even after announcing that its study in Mexico "indicate[d] that in some cases, supplies donated may be used in ways that discourage breastfeeding," Nestle agreed only to "work with international health advocates, health ministers and other manufacturers to develop normal procurement channels for infant formula for the limited number of infants who must use it."

 These stalling tactics have served Nestle well. Although it first promised to abide by the International Code in 1984, Nestle has never stopped supplying free formula to hospitals. Now that hospitals have become dependent on these donations, Nestle and other members of the International Infant Food Manufacturers (IFM) contend that they cannot stop these donations until they are directed to by individual governments. An official August 1991 statement from Nestle said the company "agrees that the controversy over this issue would certainly be resolved if such supplies were bought by governments through normal procurement channels, and that manufacturers were not obliged, as they are presently, to supply infant formula in this way."

 In June 1991, it appeared that the IFM companies had finally agreed to stop providing free supplies. When a letter from Peter Borasio, president of the IFM to James Grant, executive director of UNICEF, was made public, however, it turned out the IFM promised nothing more than "to work with WHO and UNICEF in a country by country process aimed at the development by governments of regulatory or other official measures as appropriate." Appearing to work with WHO and UNICEF enables the companies to polish their tarnished images while continuing to hook potential customers on free supplies.

Nasty Nestle

 Nestle has a history of trying not only to improve its image but to discredit the IBFAN movement and the boycott campaigns in particular. In 1988, Nestle published and widely circulated a critique of the boycott. In the document, Nestle quoted the few phrases from a generally positive internal WHO working paper that were critical of IBFAN's working methods. Following a complaint about public use of internal WHO documents, Nestle was forced to apologize to WHO, but in July 1989, another IFM member used phrases from the same document in a letter to a British politician.

 In 1989, a plan to "neutralize critics" of Nestle, devised by the public relations firm Ogilvy and Mather, was leaked to the public. Nestle claims it rejected the plan, called "Proactive Neutralization: Nestle Recommendation Regarding the Infant Formula Boycott." Among the plan's proposals were "interest group assessment and monitoring" and "initiat[ing] an early warning system through which Nestle gains awareness of actions being planned, and is equipped to take appropriate proactive or reactive steps" [see Nestle Undercover," Multinational Monitor, May 1989].

 In July 1991, Nestle publicly criticized the Baby Milk Action Coalition (BMAC), the IBFAN group principally organizing boycott efforts in Europe. Caught off guard by a motion before the General Synod of the Church of England to endorse the boycott, Nestle sent a letter from P.H. Blackburn, the company's chair and managing director, to every member of the Synod. Blackburn wrote, "I feel you should know that the promoters of this motion rely on information provided by the æBaby Milk Action Coalition.' This information is demonstrably biased and inaccurate and totally misrepresents the facts which are vitally important in considering how to contribute to improved maternal and child health."

 Despite this appeal, the General Synod's motion was overwhelmingly adopted. Nestle responded by writing to 14,000 Church of England clergy members, asking that the vote be rescinded on the grounds that the corporation had not been given an opportunity to present its side of the story. Both the Bishop of Leicester, Tom Butler, and the Synod Secretary-General, Philip Mawer, defended the vote, stating that they were well informed of Nestle's position before the vote was taken.

Promoting a breastfeeding culture

 Infant formula industry critics have not limited themselves to opposing the practices of the baby food manufacturers. They are also pursuing positive initiatives to promote breastfeeding, and have successfully prodded UNICEF and WHO to join their efforts. In 1990, UNICEF sponsored a meeting in Florence, Italy of high-level government policymakers on "Breastfeeding in the 1990s: A Global Initiative." The officials adopted the Innocenti Declaration, which sets goals and policies for what James Grant, the executive director of UNICEF, has called a "massive shift" to a "breastfeeding culture."

 At a follow-up to that meeting, UNICEF convened a special meeting of representatives of private voluntary organizations to discuss implementing the goals set in Florence. The organizations decided to form the World Alliance for Breastfeeding Action (WABA). According to Anwar Fazal, a former president of the International Organization of Consumers Unions and a founder of WABA, "the new global alliance, with the support of UNICEF, is set to become a formidable force in the transformation to a breastfeeding culture. The lives of some one million infants a year depend on it."

 In August 1991, WABA helped UNICEF and WHO launch the Baby Friendly Hospital Initiative, which encourages hospitals around the world to support women in their desire to breastfeed. Hospitals that implement certain policies, practices and routines that enhance the initiation of breastfeeding in their maternity wards will be designated as "baby friendly." The campaign is needed, according to a UNICEF pamphlet, because "the majority of hospitals in industrialized, as well as developing countries, are not supportive enough of breastfeeding."

 The focus on the infant formula industry has not been lost, however. Another major component of the breastfeeding initiative is UNICEF and WHO's call for manufacturers "to end free and low cost supplies by the end of 1992." The companies have promised to cooperate, but their promises look as hollow as they have been since 1984.